1124035191 NPI number — PINE RIVER EYE CENTER, INC.

Table of content: DR. FATIMA RIZWAN FAZILI M. D. (NPI 1679740674)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124035191 NPI number — PINE RIVER EYE CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PINE RIVER EYE CENTER, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ASSOCIATES IN EYECARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124035191
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 457
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PINE RIVER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56474-0457
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-587-2020
Provider Business Mailing Address Fax Number:
218-587-3229

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
424 BARCLAY AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINE RIVER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56474-0457
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-587-2020
Provider Business Practice Location Address Fax Number:
218-587-3229
Provider Enumeration Date:
08/02/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MARVIN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
218-587-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1895 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)